Levonorgestrel releasing IUS (Mirena®) after abortion

S.Rogovskaya, MD,PhD

The Research Center of Obstetrics, Gynecology and Perinatology,

Russian Academy of Medical Science,

Moscow, Russia

202 190,1 191,9 186 173,7 170,7 156,2

89 67,5 64,5 60,3 57,3 53 50,5

0

100

200

300

1992 1995 1996 1997 1998 1999 2000

на 1000 женщин фертильного возраста на 100 родов

Abortion and gynecological morbidity

(MH RF)

Abortion number 0 2 -3 6 -7

Risk of gynecological morbidity %

3 -4 18 -20 100

The higher the number of abortions –The higher the risk of gynecological diseases

N.Nikiforovsky et.al, 2000

Abortion rates in RF

Special demands for contraception after abortion

Long-term

Reversible

Effective Safe Easy to use

Reasons to initiate contraception

immediately after abortion

The return of fertility after a first trimester abortion is very rapid

For women, who usually do not visit a doctor and might not come to a control visit after abortion - an optimal opportunity to initiate contraception is immediately after the procedure

Contraception after abortion (tipical use)

Method Pearl indexCOP 1-3

Injection 0,3– 1,0

Implants 0,2-1,0

IUD 0,1 – 3,9

Barrier 5 –25

Sterilization 0,2 – 1,0

Natural 10-30

V. Prilepskaya, 1998

Intrauterine levonorgestrel- releasing system was developed to combine

contraceptive and therapeutic properties of hormonal agents with advantages

of intrauterine devices

Long lasting Active progestin Antiestrogenic effect Antiproliferative action on endometrium No metabolic effect Therapeutic properties

Advantages of LNG IUS

Lighter periods Reduces dysmenorrhea Beneficial effects on adenomyosis

and leiomyomas Effective treatment in menorrhagia Decreases the need for hysterectomies Protection from endometrium hyperplasia during hormonal therapy (HRT) Intrauterine release of 20µg LNG/d Approved for 5 years Pearl-index ~ 0.1

Maia et al, Gyn&Endocr 2005; Grigorieva et al, Fertil&Steril 2003; Hurskainen et al, JAMA 2004

Various aspects of LNG-IUS were studied in Research Center of Obstetrics,

Gynaecology and Perinatology for 8 years

Two studies were carried out within

framework of WHO and FHI.

Published: 1 monograph, 30 articles in domestic and foreign magazines, 16 reports at congresses,

conferences and symposia.

Detailed survey in 1126 women.

V. Prilepskaya, L.Ostreykova, A.Tagieva, 2005

LNG-IUS in women with diabetes

The continuation rates per 100 women with diabetes mellitus type I

86.7% (95% CI, 68.8-100)

The small amounts of levonorgestrel absorbed systemically from LNG-IUS do not impair glucose metabolism

S.Rogovskaya et al, The AmericanCollege of Obstetricians and Gynecologists 2005

Glycosylated haemoglobin at baseline and follow-up by treatment group

S.Rogovskaya et al, 2005

Mirena-IUS after surgical abortion: the first study

Immediate postabortal insertion of a LNG-releasing IUS compared with Cu-IUD n= 60

Both devices well tolerated LNG-IUS - regular cycles in 75% at 1 year Cu-IUD - regular cycles in all

Continuation rate 75% at 1 year

Heikkilä et al., Contraception, 1982; 26:245-59

12-month multicenter trial comparing Mirena® and Nova T®

Alltogether 2758 women 1821 in Mirena group 937 in NovaT group

440 (16%) postabortal insertions immediately after abortion or in 2 weeks

Luukkainen et al 1987

Cumulative 12-month events per 100 women

Event NovaT Mirena NovaT Mirena

Pregnancy 0.8 0.1 2.1 0

Expulsion 3.0 2.8 8.3 6.8

Mestrual/pain 7.5 9.0 7.7 7.9

Hormonal 0.1 2.6 0 1.7

Other medical 1.9 2.3 9.2 7.1

Personal 2.8 2.5 1.8 2.7

Continuation 83.9 80.8 71.3 73.8

Menstrual Interval Postabortion

Luukkainen et al 1987

Results of 12-month study Pregnancies

Mirena group 0 NovaT group 2.1 / 100 women

Expulsion rate higher in postabortion insertions NovaT 3.0 vs 8.3 Mirena 2.8 vs 6.8

Removals for other medical reasons Most usual in postabortal NovaT group (9.2/100)

Removals for hormonal reasons Most usual in menstrual interval Mirena group (2.6 / 100)

Luukkainen et al 1987

Postabortal contraception with the Mirena, Norplant, and traditional methods

Turkey 50 women in each group Pregnancy < 10 weeks Insertion of Mirena or Norplant implants was

done immediately after the evacuation

of the uterus 12 month follow-up

Ortayli et al 2001

Postabortal contraception with the Mirena, Norplant, and traditional methods

Pregnancies Mirena 0, Norplant 0, traditional method rate 8/100

Continuation rates at 12 months 96 % for Norplant and 90% for Mirena

Expulsions 2 in Mirena group

Bleeding and spotting After 5th week no difference between the groups in bleeding

Ortayli et al, 2001

Postabortal contraception with the Mirena,

Norplant, and traditional methods

Satisfaction with the methods Most of the users of hormonal methods were

satisfied with their method Easy to use Safe Effective

The Mirena users appreciated the reduced menstrual bleeding

Ortayli et al 2001

Randomized comparison of LNG and Cu-releasing IUS’s immediately after abortion - a 5-year follow-up

Multicenter study in Denmark, Finland, Hungary, Norway and Sweden

Surgical abortion of pregnancies up to 12 weeks

Randomized for Mirena (305 patients) or Nova-T (133 patients)

IUS inserted immediately after curettage

Pakarinen et al., Contraception 2003; 68: 31-34

LNG vs Cu-IUS’s after abortion

Reasons for discontinuation (/100 women)

1 year 5 years p Cu LNG-IUS Cu LNG-IUS

Pregnancy 2 0 9.5 0.8 <0.0005

Expulsion 8.6 7.1 15.4 10.5 ns

Bleeding 7.7 5.8 22.6 13.7 ns

Amenorrhea 0 1.6 0 2.1 ns

Pain 1 2 10.8 5.5 ns

Hormonal 0 2 3.9 15.9 <0.01

Pakarinen et al., Contraception 2003; 68: 31-34

Reasons for discontinuation

2 pregnancies in Mirena group - (Occurred during the 4th year)

The first pregnancy was terminated by curettage and no IUS was found

The second pregnancy was after an unnoticed expulsion

The incidence of expulsions, bleeding problems, pain and pelvic inflammatory disease (PID) Not significantly different between the groups but tended to be

lower in the Mirena group

Pakarinen et al., Contraception 2003; 68: 31-34

Reasons for discontinuation

Planning pregnancy 11.5 for NovaT and 17.7 for Mirena High figures show the importance of a reversible method

Amenorrhea Terminations occurred during the use of Mirena

The cumulative gross rate was low, 2.1 at 5 years

Bleeding disorders Tended to be lower in Mirena group

Hormonal reasons higher with the Mirena than NovaT

Pakarinen et al., Contraception 2003; 68: 31-34

Mirena®-IUS following medical abortion at Women’s Hospital, University of Helsinki

417 women chose medical abortion between VIII/2000 and VIII/2001 Duration of pregnancy up to 8 weeks Analysis of efficacy, learning curve and future contraception

29% chose IUS/IUD for future contraception 16% (n=65) Mirena 13% (n=53) Cu-IUD

55% of the IUD’s inserted at the control visit at 3 weeks following mifepristone 25% inserted at later occasion at the clinic Insertions without complications

Suhonen et al., Contraception 2003; 67: 223-7

LNG-IUS after abortion in RC OGP, Moscow

N=37 12 months follow-up Effective (no pregnancies) Safe, no serious adverse effects Most reasons for discontinuation – bleeding,

spotting Continuation rate 82%

V.Prilepskaya, A.Kuzemin, 2004

Mirena-IUS after abortion summary

Mirena-IUS is highly effective for postabortal contraception (Pregnancy rates low, IP=0.1-0.2)

Mirena-IUS can be safely inserted: at the time of 1st trimester surgical abortion or 2-3 weeks after medical abortion

High rate of discontinuation of Mirena due to wish for pregnancy - emphasises the importance of reversibility of contraception

Mirena-IUS after abortion summary

Counselling and insertion technique are important (expulsions increased)

Easy method for women Effective immediately after insertion, long-term 5 yrs No daily remembering Offers added health benefits

Reduction of menstrual bleeding Better iron balance and prevention of anaemia Reduces dysmenorrhea, smaller risk of bleeding due to

adenomyosis and leiomyomas Effective in menorrhagia

Mirena – method of contraception after abortion

Effective

Safe

Reversible

5 years